Beta-blockers show no benefit in preserved LVEF post-MI, but may help mildly reduced LVEF

BackgroundFor several decades, beta-blockers (BBs) have served as a cornerstone in the secondary prevention following myocardial infarction (MI). However, contemporary randomized evidence has challenged the long-term BB use in patients with preserved or mildly reduced left ventricular ejection fraction (LVEF) in the era of percutaneous coronary intervention and comprehensive guideline-directed medical therapy.MethodsWe summarized evidence from three randomized controlled trials and two contemporary meta-analyses, evaluating BB therapy in post-MI patients with preserved or mildly reduced LVEF. We critically appraised trial designs, endpoints, and outcomes stratified by LVEF, and reviewed current guideline recommendations from North American and European perspectives.ResultsIn patients with preserved LVEF (≥50%), pooled data demonstrated no reduction in death, MI, or heart failure with BB therapy (P = 0.54). By contrast, among patients with mildly reduced LVEF (40%–49%), BB was associated with a 25% relative risk reduction in the composite endpoint (P = 0.031), with no between-trial heterogeneity. Safety profiles were comparable between BB and no-BB groups across all trials.ConclusionContemporary evidence supports an EF-stratified approach to BB therapy after MI. Routine long-term BB prescription may no longer be justified for patients with preserved LVEF (≥50%) without other indications, whereas BB therapy may be reasonable to consider for those with mildly reduced LVEF (40%–49%). These findings support an EF-stratified approach to long-term BB use after MI in contemporary practice.